Healthcare Provider Details

I. General information

NPI: 1932613213
Provider Name (Legal Business Name): CARISSA LYNN BREDE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2017
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463142 STATE ROAD 200
YULEE FL
32097-5554
US

IV. Provider business mailing address

463142 STATE ROAD 200
YULEE FL
32097-5554
US

V. Phone/Fax

Practice location:
  • Phone: 904-225-8280
  • Fax: 904-225-8232
Mailing address:
  • Phone: 904-225-8280
  • Fax: 904-225-8232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH17642
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: